Wiki level 4 new OV requirements

[sacash]

I received this email from on of my doctors and has me questioning myself.

"For a level 4 office visit (new), the auditing sheets you've shown me/us in the past indicate that the exam has to be "comprehensive" and include 8 or more systems. Is that correct?

To further clarify, if I included vitals (constitutional), pulses (cardiovascular), skin, neuro (sensation/strength), musculoskeletal (ROM, strength), Psych, spine---that would equal 7 systems, correct? There is a checkbox for "each extremity" on the auditor sheets you've used before: would that then make it 8 systems if I discuss both the right and left legs?

Just want to be sure....if the above is accurate, I could easily do level 4 on my NP and cover it all."

Any thoughts?? Thanks!

 

[dclark7]

In order to be "comprehensive" eight Organ systems must be documented. Spine and extemities are considered "body areas" and cannot be counted for a comprehensive exam.

Organ systems are Constitutional, Cardiovascular, Eyes, ENT, GI, GU, Musculoskeletal, Neurologic, Pshyc, Respiratory and Skin.

Body areas are Head (including face), Neck, Chest (including breast and axillae), Abdomen, Genetalia (groin and buttocks), Back (including spine) and Each extremity.

For more information you could get the MLN Evaluation and Managment Services Guide which is on the CMS website. http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

 

[Lynda Wetter]

I received this email from on of my doctors and has me questioning myself.

"For a level 4 office visit (new), the auditing sheets you've shown me/us in the past indicate that the exam has to be "comprehensive" and include 8 or more systems. Is that correct?

To further clarify, if I included vitals (constitutional), pulses (cardiovascular), skin, neuro (sensation/strength), musculoskeletal (ROM, strength), Psych, spine---that would equal 7 systems, correct? There is a checkbox for "each extremity" on the auditor sheets you've used before: would that then make it 8 systems if I discuss both the right and left legs?

Just want to be sure....if the above is accurate, I could easily do level 4 on my NP and cover it all."

Any thoughts?? Thanks!

If he is documenting 7 for a new patient that would place it under "detailed"
Yes 8 or more would be comprehensive and would place that under a Level 4 visit ...keep in mind for a good supporting note I would not accept simply "normal" or "abnormal" as findings on his exam.